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17 July 2007 : Column 38WH—continued

I would like to put on the record some of the areas in which we have made improvements. In 2002, we
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welcomed the sponsorship by the National Institute for Health and Clinical Excellence of a national clinical audit of epilepsy-related deaths. The audit looked at investigations into those deaths, care provided prior to death, and contact with bereaved families. In 2003, we followed up the audit with the publication of our epilepsy action plan, which drew the attention of clinicians and local health organisations to the need to establish or review policies and practices regarding the management of epilepsy and epilepsy-related deaths. My hon. Friend the Member for Pudsey (Mr. Truswell) raised the issue of the coroner and the hon. Member for Eddisbury discussed what we need to do with coroners’ reports and with pathology. I can assure hon. Members that we will consider all those detailed questions and seek to address them. If I receive an invitation from the all-party group, perhaps I could bring more information on those issues to a meeting.

The Department of Health commissioned NICE to produce a clinical guideline for the diagnosis, management and treatment of epilepsy, which was published in 2004. Additionally, the national service framework for long-term conditions, which was published in March 2005 and about which I will speak in more detail later, focuses on improving services across England for a range of neurological conditions, including epilepsy. Through the quality and outcome framework, we have also taken steps to ensure that GPs provide good quality care for people with epilepsy. Undoubtedly, we will have to look at different levels of training and monitor what happens to patients who present to their GP and how we follow up those cases. It is too early to tell how many practices have been successful in this area, but we will know later in the year when QOF data on the 2006-07 financial year are published.

The diagnosis and the importance of MRI scans and sleep electroencephalograms has also been mentioned. We are making good progress on waiting times for MRI scans, which are crucial for early diagnosis and intervention, as mentioned by the hon. Member for Romsey (Sandra Gidley). Between January 2006 and 2007, over 13 week waits fell by more than 90 per cent. from, I believe, 20,585 to 1,959. Over 26 week waits have fallen by more than 99 per cent., and I believe that now only 23 people, who have a range of conditions, are waiting more than 26 weeks for a MRI scan. We need to do more, but I am sure the hon. Lady will agree that that is a huge improvement. That figure compares with almost 5,000 when we started collecting data. Clearly, we have done much to support NHS organisations in improving epilepsy services. However, I know of the often-voiced concern that without targets or dedicated funding there is neither the power nor the incentive to force through improvements.

National standards will always be necessary to protect people against inequalities in service provision, but in taking forward our improvement and reform agenda we need a decisive shift from top-down to bottom-up as we develop a devolved and self-improving health service, in which the main drivers for change are patients, commissioners and clinicians, rather than national targets and performance management. The all-party epilepsy group’s report and the witnesses
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that gave evidence very ably will do an awful lot to bring about a patient-centred epilepsy service.

Effective commissioning by primary care trusts is paramount. We expect local commissioners and providers to reprioritise the way in which existing resources are used to better meet the needs and wishes of their population. The changes are being supported by a programme of reforms that include the choice agenda, payment by results and practice-based commissioning. However, all Members present will understand that to deliver positive changes on the ground to health care, we need good leadership on the ground. It is for my Department to encourage and monitor that leadership, because although to devolve responsibility might be a comfortable solution, we cannot walk away. Leadership should come at a national and local level, and I give my assurances that I shall monitor that leadership to ensure that we make that progress.

Mr. Stephen O'Brien: I am very interested in the point that the Minister is making. She is absolutely right. However, does she agree that leadership can be provided as much by those with clinical responsibilities as by managers?

Ann Keen: I agree absolutely with the hon. Gentleman, which is why the review of the NHS in general is being led by clinicians at every level, by people who work in the service and by patients. The review undertaken in London by my colleague the Parliamentary Under-Secretary of State for Health, Professor Sir Ara Darzi, and that for the rest of the NHS managed that very successfully. There is no other way of doing it; users and their families, clinicians, from the top dogs, so to speak, right the way through professions allied to medicine, and all of those who work in our good national health service need to feel involved.

The hon. Gentleman was kind, again, to mention my specialist interest. Specialist nurses must be brought to the forefront. The deployment of specialist nurses is of particular concern to stakeholders, and the all-party epilepsy group’s report requests an immediate commitment to increase the number of epilepsy specialist nurses to 600. Before I respond to that point, however, I take the opportunity to commend the work of Epilepsy Action, which through the Sapphire nurse scheme is doing sterling work to support the appointment of specialist nurses in hospitals throughout the United Kingdom.

I can totally reassure my hon. Friend the Member for Calder Valley that we support maximising the use of the specialised skills of specialist nurses. Indeed, we are proud that the UK leads the world in the development of specialist nursing roles. We ignore the nurse at our peril!

Mr. O'Brien: Tell me about it.

Ann Keen: I thought the hon. Gentleman would be able to relate to that.

Decisions, however, on the skill mix required for patient care are best made at a local level. It is for local health economies to determine how many specialist nurses they require and to prioritise the resources needed for the necessary work force development.
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Nevertheless, we want to ensure that local health economies are encouraged to utilise fully the skills and experience of specialist nurses. In May, the Under-Secretary of State for Health, my hon. Friend the Member for Bury, South (Mr. Lewis), held a summit with the MS Society, Epilepsy Action, the Parkinson’s Disease Society and the Royal College of Nursing to discuss those very concerns. There was an agreement to produce best practice guidance and to encourage PCTs to advocate the role of specialist nurses across the country.

Having enough staff with the right skills and experience, who are well led and well supported, is of course key to implementing the national service framework for long-term conditions. The national service framework is now our key delivery mechanism for improving services for people with neurological conditions across England. The hon. Member for Romsey asked about the number of neurologists. I believe that the answer is 437. So we have areas to look at concerning the number of neurologists. However, people with neurological conditions will get a faster diagnosis, more rapid treatment and a comprehensive package of care. In addition, all people with long-term conditions will be supported so that they can live as full and independent a life as possible. Those are some ambitious plans. I am very aware of the implications of saying them; implementation is a different matter.

The hon. Member for Chesham and Amersham (Mrs. Gillan) invited me to see work being done in her constituency, and I acknowledge the work that she has done and the spirit in which she made her comments. It is important that the Government and the all-party epilepsy group reflect on that matter and look at how we can work together to bring about the necessary long-term changes.

Successful implementation of the national service framework is of vital importance to us. We are working with a range of key stakeholders to identify and develop practical tools and advice that can help local services and organisations to deliver the NSF. That means that services for people with neurological conditions from diagnosis to the end of life will progressively improve.

My hon. Friend the Member for Calder Valley has been successful not only in securing this debate, but in bringing to it the enthusiasm that she brings to everything that she has done since she has been a Member of the House. I know that in the work that she has done through listening to witnesses for the report, she has not pushed the matter to one side. She has approached it with the commitment that she has brought to everything else since she has been a Member of the House. At this point, it is particularly important that we raise the good practice taking place already. It is easy to place too much emphasis on what is not working rather than reflecting on and celebrating what is working well. Yes, there are problems and yes, the
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case for improving the quality of services overall is compelling, but that should not overshadow the good work that is currently taking place.

For one example of good practice, I would like to mention King’s College hospital, which is providing a comprehensive service from diagnosis to treatment. High quality care is being provided also through the community-based service in east Kent. That is an example of the direction of travel in which we want to see services going, which would embrace networks of general practitioners, with a special interest, and epilepsy nurses working in collaboration with the local neurology service.

Through the national service framework, NICE guidance and the epilepsy action plan we have set out very clearly what the expectations are for the pattern of services for people with epilepsy. We have mentioned, in this debate, the services to prisoners and those in our prison care service. Much work has to be done, and I give another commitment to work with colleagues in the Ministry of Justice to ensure that that takes place.

I might not have managed to answer other questions, in particular those concerning new light bulbs and the Olympic logo, but they are serious issues. It is important that we really assist those with neurological symptoms and problems, under a diagnosis of epilepsy, and that they are seriously catered for, as they would be if they had any other condition causing alarm to them and their families.

Mr. O'Brien: The Minister might want also to bring the Department for Transport into her joint working approach, because often those diagnosed with an epileptic condition find it very difficult, not least because they have to rely on so many others for their transport needs, as often they cannot secure a driving licence. That is another area that could be joined up.

Ann Keen: I thank the hon. Gentleman for that intervention. Yes, I would take that forward, because travel is so important to any age group. Someone who has had to lose their driving licence may find it very difficult to explain that to friends and family. Perhaps they will not raise it and family members will not want to say, “This is why we have a difficulty.” That situation is not easy and I relate to it exceptionally well.

We take the findings of the APPG’s report seriously, as I hope my response today has shown. Reforming health care is all about finding out the facts, identifying the problems and facing up to the challenges with strategic solutions. We share the desire of my hon. Friend the Member for Calder Valley for people living with epilepsy to receive the services that they need and deserve. I assure her that the Government will continue to provide support and leadership to the health service to ensure that that happens. Leadership locally, which my hon. Friend has shown, can perhaps encourage us all to deliver leadership throughout the health service.

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Cancer Screening

12.21 pm

Dr. Vincent Cable (Twickenham) (LD): I am delighted to have the opportunity to introduce a debate on cancer screening, which is a continuation of an interest that I have had ever since I entered the House. I had debates on cervical cancer screening in 2001 and on screening in general in 2003. As the Minister may have guessed if she has had an opportunity to see the record, I want to use this debate to take forward the questions that I was raising at that stage. I have two reasons for wanting to do so. First, I am conscious that this issue is of very great concern to my constituents, particularly women. I discovered in 2001 that there was a major campaign in my constituency and 5,000 women wrote to me, specifically requesting that I raise in Parliament the issue of how to improve cervical cancer screening, as new technology was becoming available that would reduce the risk of omissions from the screening process.

As I explained in the previous debate, I also have a personal motivation: I lost my wife to breast cancer. She was diagnosed aged 43 and I have always been haunted by thoughts of whether, if screening had taken place for women in their 40s as opposed to 50s and 60s, her cancer would have been picked up at an earlier stage and she would have been saved.

In general, cancer screening is one of the great success stories of the NHS. It is more advanced than in almost every other developed country. It has been done on a mass scale, certainly for cervical cancer and breast cancer, for many years and many lives have been saved as a consequence, so it is a positive story, and big advances have been made in the past 10 years in respect of the big three cancers to which screening applies. I want to acknowledge that, while asking questions about the process.

It clearly appeals to elementary common sense to suggest that if we have screening, conditions can be picked up at an earlier stage, avoiding not just premature death but unnecessary surgery. I recognise, of course, that there are limits to that process. There are limits to screening technology, which mean, for example, that it is not applied in the case of some cancers. Prostate cancer is one for which there is not sufficient precision. I also recognise that there has to be a test of cost and benefits. We cannot just have indiscriminate screening of all age groups for all conditions.

Initially, I shall ask a few questions and pursue the issue of cervical cancer screening, in respect of which there have been major advances. There is a long history in Britain, through the smear test, of saving very large numbers of women from that condition. Some of the progress is recognised in the fact that we screen 3.5 million women annually; I understand that there is 80 per cent. coverage. Roughly 4,500 lives a year are saved as a result of the screening process, and I think that deaths have now come down to fewer than 1,000 a year. That is a major success story, with continually falling death rates since about 1990. The big transformation in recent years has been the introduction of the liquid-based cytology tests, which
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are much more accurate and avoid the 20 per cent. failure rate that occurred under the old testing system.

If the Minister does not have the answers to my questions to hand, I hope that she will write to me. First, since the new LBC system was successfully introduced in Scotland—I think that that was completed by 2004—why has it taken so long to spread it through England? Can she give us some clarity about when the roll-out is expected to be completed? I understand that we are talking about next year, but is it the beginning or end of next year? Is that known?

Secondly, there are substantial disparities between the home countries in respect of the age groups covered by the smear testing arrangements as enhanced by the LBC test. The age group is 20 to 60 in Scotland, 20 to 65 in Wales and 25 to 64 in England. There is nothing wrong with that at all—indeed, there is much to be said for experimentation and trying different approaches—but what lessons have been learned from those different age profiles? Does one work better than another? Can we learn from Wales and Scotland? Are there any proposals to adapt the age profile?

Thirdly, can the Minister confirm the worry that some cancer charities have expressed? One in particular, called Jo’s Trust, has written to me and I met representatives at a reception in the House of Commons. It is particularly concerned with young women and has pointed to the fact that there appears to be a serious tailing off in the number of young women in their late 20s who are going for the screening. Have the Government analysed that? Do they know the reasons for it and do they have any answers to it?

My final set of questions about cervical cancer screening relates to the new technology that is becoming available as a result of the understanding that, unlike other cancers, cervical cancer is caused by a virus—a sexually transmitted virus. I think that the science was developed in the mid-1990s, and out of the understanding of the human papilloma virus come various potentialities. The first is whether the knowledge of HPV is being incorporated in screening: is it being used as part of the new screening process with LBC?

Secondly, the technology now makes it possible to vaccinate against cervical cancer. The Government were right and, indeed, quite courageous to bring in the new programme, which involves vaccinating girls before they leave school. It is hoped that that will greatly reduce the incidence of the disease at an early stage in its transmission. However, the cancer charities that are following this issue have raised various supplementary questions about that and perhaps the Minister will reflect on them. First, it appears that the next school year will be missed. I do not know whether that is correct; perhaps the Minister will confirm it. If it will be missed because of the difficulties of introducing vaccination across the board, what will happen to that age group? Will there be a follow-up, with encouragement and support in getting GP referrals to catch up?

What plans do the Government have to deal with what we might call the missing age group? I am referring to those young women who are too old to have caught the new vaccination programme at school, but who are too young to have the smear test, because they will not get it until they are 25. There is a 10-year group of young women who are missing altogether. What are the plans to deal with that? Is there a system
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of enhanced GP referral, for example, which would enable them to be captured?

I also have some questions for the Minister about the progress being made in the breast cancer screening programme. That, too, is a major success story for the NHS. It has been going for a very long time, particularly for women aged 50 to 64, and the age group has now been expanded by five years, which is a very welcome step. The analysis shows that about 1,400 lives a year are being saved. As with cervical cancer, there is clinical evidence of a substantial disparity between the survival rate for those who are screened, which is about 95 per cent. over five years, and the survival rate for those who are not screened. The difference, however, is that breast cancer numbers are rising substantially, whereas cervical cancer numbers are falling, and I wonder whether that might have something to do with the difference in the take-up of screening.

One thing that I find difficult to understand is why the take-up of breast cancer screening is significantly lower than the take-up of cervical cancer screening. After all, we are talking not about young women, but about mature women, who are presumably very conscious of their health. We are also talking about the same obstacles in terms of information and literacy. Why, then, should the take-up for breast cancer mammographic screening be significantly lower than for cervical cancer screening? The figure for breast cancer screening is about 75 per cent. on average, as against 80 per cent. for cervical cancer screening. In my area, as the Minister will know because she lives close by and represents a constituency next to mine, breast screening take-up is well below the national average, even though people are generally fairly prosperous and well educated. I have asked the primary care trust to address some of the technical problems, such as the location of the screening site and so on, but the figure is still low, and I wonder how much work has gone into understanding why take-up rates are low and whether they can be improved.

The big issue on breast cancer screening is age, and as I explained to the Minister, I have a personal interest in pursuing this. Everybody welcomes the extension of screening to older women, but the outstanding question is whether there would be value in extending it down the age range to women between 45 and 50 or between 40 and 50. When I last asked that question four years ago, the Government felt that the evidence was not compelling. There have been some pilot studies since then, and I wondered whether there had been any rethink about the desirability of extending the age range to catch younger middle-aged women, substantial numbers of whom get cancer.

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